Patients in the intensive care unit (ICU) are usually the sickest in the hospital and require a ton of care. Unlike a normal patient note, which is generally brief and written in the SOAP format, the ICU note is more thorough and exhaustive. Below is a discussion of how an ICU note can be organized so that important information is not missed. Please note that this is not the only way to organize an ICU note, but it is a way that many units use because it is extremely thorough and organized.
Organize by Systems
The beginning of any ICU note should always have the patient’s name, date, time, hospital day, post operative day (if in the surgical ICU), lines (ie: any tubes going into or out of the patient), and drips.
- Patient’s name
- Hospital day
- Post operative day (if applicable)
- Lines
- Drips (often abbreviated as “gtts”)
Unlike normal floor notes, which are typically organized by problem, ICU notes are more commonly organized by body system. The systems are usually written in the following order:
- Neurological
- Cardiovascular
- Respiratory (pulmonary)
- Renal
- Fluids, electrolytes, nutrition (FEN)
- Infectious disease
- Hematology
- Gastrointestinal
- Endocrine
- Psychiatric
- Prophylaxis
So what information should we include in each section?
At the bare minimum the neurological part of the note should include the patient’s alertness and orientation (ie: “AAOx3, confused, intubated but following commands, etc.”), and their Glasgow coma scale (GCS) score. If the patient is in the neuro-ICU the exam should be more thorough and include the GCS score by component, as well as a neurological exam. A common question asked by neuro-intensivists is “what can the patient do?” Do they follow all commands? Do they withdraw to pain? Are they decorticate? Decerebrate? Give a description of what the patient can “do” or “not do”.
Less commonly some ICU patients may have an external ventricular drain or lumbar drain used to remove cerebrospinal fluid. If this is the case the output of the EVD or lumbar drain should be recorded. EVDs are set to a specific height above the tragus of the ear; this number is important to record as well.
Finally, specific medicines related to neurological disease should be added. Any medications used to sedate or paralyze the patient should also be included as they may confound the physical exam findings. For example, are they on propofol or fentanyl drips? How much of this medicine is “dripping” into them per hour? Someone on a large amount of fentanyl may not respond much to painful stimuli so it is important to give a description of what may be confounding your examination.
To recap, the neurological section should include the following elements:
- Physical exam findings
- Level of alertness and orientation
- GCS broken down by components
- Neurological exam (ie: cranial nerves, strength, reflexes, sensation, etc.)
- Vital signs and tubes
- EVD and/or lumbar drain output
- Output over last shift
- Output over last 24 hours
- Height of the EVD
- Neurological medicines
- Sedatives (ie: propofol, midazolam, etc.)
- Pain medications
- Treatment specific medications (anti-seizure meds)
In addition to physical exam findings, the cardiovascular section should start off with the heart rate, rhythm, blood pressure, and central venous pressure (if a central line is present). Patients with significant cardiovascular disease may have a pulmonary artery catheter (aka: Swan-Ganz catheter). The data obtained from it should also be included: pulmonary artery pressure, pulmonary artery wedge pressure, cardiac output, cardiac index, central venous pressure, and stroke volume.
The cardiovascular section of the note should also include what drips the patient is on to control blood pressure. Are they on anti-hypertensive medications or pressors?
To recap, the cardiovascular section should include:
- Physical exam findings
- Vital signs and tubes
- Heart rate
- Heart rhythm (from telemetry)
- Blood pressure
- Central venous pressure (from central line or Swan Ganz catheter)
- Pulmonary artery pressure (from Swan Ganz catheter)
- Pulmonary artery wedge pressure (from Swan Ganz catheter)
- Cardiac output and index (from Swan Ganz catheter)
- Chest tube output (if present)
- Output over last shift
- Output over last 24 hours
- Cardiac specific medications
- Intravenous drips used to control blood pressure
- Other cardiac medications (β-blocker, ACEI, etc.)
In addition to physical exam findings, the most important thing to include in this section are the ventilator settings. It should be organized in the following way: mode, FiO2, tidal volume, patient’s respiratory rate, ventilator’s rate, peak end expiratory pressure (PEEP), pressure support, peak airway pressure.
After the ventilator settings, the patient’s oxygen saturation should also be stated.
Any laboratory data specific to the pulmonary system is given next. This commonly includes arterial blood gas values written in the following order: pH, PaO2, PaCO2, and HCO3. Chest x-ray results should also be written here.
To recap, the respiratory portion of the note should include:
- Physical exam findings
- Ventilator settings
- Mode
- FiO2
- Tidal volume
- Patient’s respiratory rate
- Ventilator’s respiratory rate
- Peak end expiratory pressure (PEEP)
- Pressure support
- Peak airway resistance
- Vital signs
- Oxygen saturation
- Laboratory data
- Arterial blood gas results
- Chest x-ray results
- Pulmonary medications
- Nebulizers, etc.
The renal section includes an evaluation of the patient’s kidney function. The first piece of data that should be recorded are the "in and outs". The "ins" include the total amount of fluid the patient has received intravenously and orally. The "outs" include the total amount of urine the patient has made. The urine output should be recorded in mL/kg of body weight per hour, shift, and over the last 24 hours.
Laboratory data that should be recorded in the renal section includes the creatinine, blood urea nitrogen (BUN), urinalysis, urine microscopy, and any imaging studies specific to the urinary tract. You may also need to calculate and include the fractional excretion of sodium.
To recap, the renal section of the note should include:
- Vital signs
- Ins and outs
- Output over last shift
- Output over last 24 hours
- Laboratory data
- Creatinine
- Blood urea nitrogen (BUN)
- Urinalysis
- Urine microscopy
Fluids, Electrolytes, and Nutrition (FEN)
The fluids, electrolytes, and nutrition section should have what fluids, both intravenously and orally, the patient is receiving. The patient’s electrolytes should also be recorded in this section. The most common electrolytes that are measured are sodium, potassium, chloride, bicarbonate, phosphorus, calcium, and magnesium. In addition, the patients diet, either orally or intravenously should be discussed along with their nutritional status (usually measured by albumin or prealbumin levels).
To recap the fluids and electrolytes section should include:
- Intravenous fluids (ie: normal saline, hyper or hypotonic saline, colloids, etc.)
- Diet
- Laboratory data
- Chemistry panel
- Calcium, magnesium, phosphorus
- Albumin
- Prealbumin
The infectious diseases section should always begin with the maximum temperature over the last 24 hours followed by the current temperature.
After that the patient’s white blood cell count should be mentioned. If there are any pending or final culture results they should be included in sequential order. Common data recorded include blood, urine, and sputum cultures. Sometimes cerebrospinal fluid cultures will also be available.
Finally, all antibiotics the patient is receiving should be listed along with how many days they’ve been on each one.
To recap, the infectious disease section should include:
- Vital signs
- Maximum temperature
- Current temperature
- Laboratory data
- White blood cell count
- Culture results
- Antibiotics
Physical exam findings such as bruising, petechiae, oozing from surgical incisions should be mentioned.
The hematology section should have the hemoglobin, hematocrit, platelet count, prothrombin time, INR, and partial thromboplastin time. Other values that are less common, but may be present include iron studies, d-dimer results, fibrinogen levels, and mixing studies.
Since blood clot formation is a huge concern in hospitalized patients, any results related to this should be included. Studies such as lower extremity dopplers, chest CT or ventilation perfusion scans should be included in this section.
To recap, the hematology section should include:
- Physical exam findings (ie: bruising, oozing, petechiae, etc.)
- Laboratory data
- Hemoglobin and hematocrit
- Platelet count
- PT, INR, PTT
- Lower extremity doppler results
- Chest CT or ventilation/perfusion scan
The gastrointestinal section is devoted to the patient’s bowel function. A discussion of how the patient is being fed and what is being fed to the patient is written in this section. For example, oral versus intravenous feedings. Is a nasogastric tube present?
Laboratory data that should be included here are the patient’s albumin level (measured every few weeks) and the patient’s prealbumin level (usually measured every 48 hours).
Physical examination findings of the gastrointestinal tract should be written as well. They may include abnormal bowel sounds, enlarged liver or spleen, ascites, or blood in the stool.
To recap, the gastrointestinal section should include:
- Physical exam findings (ie: distended, peritoneal signs, etc.)
- Laboratory data
- Liver function tests
- Amylase and lipase
The most important thing for the endocrine section is the blood sugar results. Other common values that are often ordered for ICU patients include serum osmolality. Any medications used to control glucose levels such as insulin drips or hypoglycemic agents should be recorded.
- Laboratory data
- Blood glucose levels (fingerstick, metabolic panel)
- Medications
- Insulin drip and rate (if any)
- Sliding scale insulin
- Subcutaneous insulin
- Oral hypoglycemics (ie: metformin, glyburide, etc.)
The psychiatric portion of the note is often neglected or omitted, but is an important component to at least think about. Many psychiatric issues will be dealt with once the patient is out of the ICU.
The prophylaxis section is very important! Most patients in the ICU will be on a medicine to decrease the risk of developing gastric ulcers, as well as several methods to prevent deep venous thrombosis and pulmonary embolism. Any prophylactic measures should be listed and addressed during rounds.
The prophylaxis section includes:
- Ulcer prophylaxis
- H2 or proton pump inhibitor
- Deep venous thrombosis prophylaxis
- Subcutaneous heparin
- Compression boots (venodynes)
- Graduated/compression stalkings
To Sum It All Up…
There are different ways to organize an ICU note. By far the most common way is to organize it by systems. However, various services (ie: neurosurgery, cardiothoracic, etc) will have very specific ways they want data presented depending on what information is most important to them.
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